| History and Physical Examination (H&P): These findings are then dictated by category and usually include the following:
In this section the physician reviews with the patient the medical condition of the patient's major organ systems. They usually include Head, Eyes, Ears, Nose, Throat (HEENT); Cardiovascular (CV); Respiratory; Gastrointestinal (GI); Genitourinary (GU); Neuromuscular; Psychiatric; and occasionally Skin. | Review of Systems |
| History and Physical Examination (H&P): These findings are then dictated by category and usually include the following:
In this section the physician reviews with the patient the medical condition of the patient's major organ systems. They usually include Head, Eyes, Ears, Nose, Throat (HEENT); Cardiovascular (CV); Respiratory; Gastrointestinal (GI); Genitourinary (GU); Neuromuscular; Psychiatric; and occasionally Skin. | Review of Systems |
| History and Physical Examination (H&P): These findings are then dictated by category and usually include the following:
In this section the physician reviews with the patient the medical condition of the patient's major organ systems. They usually include Head, Eyes, Ears, Nose, Throat (HEENT); Cardiovascular (CV); Respiratory; Gastrointestinal (GI); Genitourinary (GU); Neuromuscular; Psychiatric; and occasionally Skin. | Review of Systems |
| The medical reports: Physicians in private practice frequently dictate: | chart notes, Letters, initial office evaluations, and history and physical examinations. |
| Medical reports dictated in hospitals and medical centers are numerous in category; however, they invariably include dictations from the "basic four" reports, namely: | History and Physical Examination,
Consultation Report,
Operative Report,
Discharge Summary |
| The medical reports: What were often dictated as well: | Emergency Departmental Reports, hospital progress notes, and diagnostic studies are often dictated as well. |
| Also called progress note or follow-up note
is dictated by a physician after talking with, meeting with, or examining a patient, usually in an outpatient setting, although progress notes are occasionally dictated on hospital inpatients.
Contains a concise description of the patient's presenting problem, physical findings, and the physician's plan of treatment, and may also include the results of laboratory tests.
can vary in length from one sentence to one or more pages, with the average note being two to four paragraphs long.
Are sometimes dictated in an informal, staccato style using clipped sentences, abbreviations, and brief forms. There are numerous formats for this. | Chart note |
| What is a chart note | Also called progress note or follow-up note
is dictated by a physician after talking with, meeting with, or examining a patient, usually in an outpatient setting, although progress notes are occasionally dictated on hospital inpatients.
Contains a concise description of the patient's presenting problem, physical findings, and the physician's plan of treatment, and may also include the results of laboratory tests.
can vary in length from one sentence to one or more pages, with the average note being two to four paragraphs long.
Are sometimes dictated in an informal, staccato style using clipped sentences, abbreviations, and brief forms. There are numerous formats for this. |
| Is an acronym for:
Subjective (reason for visit or chief complaint)
Objective (physical examination)
Assessment (diagnosis or impression)
Plan (course of treatment) - headings within the note. | SOAP notes |
| What are SOAP notes: | Are those dictated in the SOAP format (an acronym for:
Subjective (reason for visit or chief complaint)
Objective (physical examination)
Assessment (diagnosis or impression)
Plan (course of treatment) - headings within the note. |
| Physicians frequently dictate this to communicate patient information to other physicians, insurance companies, and government offices. | Letter |
| What is a Letter: | are frequently dictated by physicians to communicate patient information to other physicians, insurance companies, and government offices. |
| Performed in the physician's office or clinic setting, the initial office evaluation is dictated after the physician sees a patient for the first time.
It contains essentially the same information as the history and physical examination, although the physical examination in an initial office evaluation may be limited to specific areas of disease. | Initial Office Evaluation |
| What is Initial Office Evaluation: | Performed in the physician's office or clinic setting, the initial office evaluation is dictated after the physician sees a patient for the first time.
It contains essentially the same information as the history and physical examination, although the physical examination in an initial office evaluation may be limited to specific areas of disease. |
| Shortly before or after a patient is admitted to the hospital, the physician obtains the patient's subjective history and conducts an objective physical examination. | History and Physical Examination (H&P) |
| What is History and Physical Examination (H&P): | Shortly before or after a patient is admitted to the hospital, the physician obtains the patient's subjective history and conducts an objective physical examination. |
| History and Physical Examination (H&P): These findings are then dictated by category and usually include the following: | -Chief complaint
-History of Present Illness
-Past Medical History
-Family History
-Social History
-Review of Systems |
| History and Physical Examination (H&P): These findings are then dictated by category:
This is the patient's main presenting problem and the reason for which the patient is seeking medical help. It can be a short sentence ("I fainted") or a paragraph in length. | Chief complaint |
| History and Physical Examination (H&P): These findings are then dictated by category and usually include the following:
This is a description of the events leading to the patient's presentation to the physician (or admission to the hospital). It can be a few lines to one or two paragraphs in length. | History of Present Illness |
| History and Physical Examination (H&P): These findings are then dictated by category and usually include the following:
This category includes all medical and surgical problems from childhood to the present, including medications and allergies. | Past Medical History |
| History and Physical Examination (H&P): These findings are then dictated by category and usually include the following:
is the medical condition of parents, other family members, and blood relatives. A complete family history (often not elicited) includes the age and state of health of all the immediate family members. | Family History |
| History and Physical Examination (H&P): These findings are then dictated by category and usually include the following:
Contains a description of the patient's personal information-occupation, lifestyle, and habits. | Social History |
| History and Physical Examination (H&P): These findings are then dictated by category and usually include the following:
In this section the physician reviews with the patient the medical condition of the patient's major organ systems. They usually include Head, Eyes, Ears, Nose, Throat (HEENT); Cardiovascular (CV); Respiratory; Gastrointestinal (GI); Genitourinary (GU); Neuromuscular; Psychiatric; and occasionally Skin. | Review of Systems |
| Details the physician's objective findings on examination of the patient. | Physical examination |
| What is The Physical Examination: | The Physical Examination details the physician's objective findings on examination of the patient. |
| result when one physician requests the services of another (usually a specialist) in the care and treatment of a patient. | consultation |
| What is consultation: | Consultations result when one physician requests the services of another (usually a specialist) in the care and treatment of a patient. |
